Healthcare Fraud Shield’s Latest Article: Test Your Data for Genetic Testing

12 Sep
Genetic Testing.  It’s a big buzz word lately, and for many payers genetic testing is also an area of rapidly increasing spend.  It may come as a surprise that there is little regulation of genetic testing, making it an even more lucrative area for potential fraud, waste and abuse.  According to the National Human Genome Research Institute[i]:

The Food and Drug Administration (FDA) has the authority to regulate genetic tests, but it has to date only regulated the relatively small number of genetic tests sold to laboratories as kits.  Whereas the Centers for Medicare and Medicaid Services (CMS) does regulate clinical laboratories, it does not examine whether the tests performed are clinically meaningful.

In addition to the lack of regulations, genetic testing services can be complicated and intimidating to non-clinical investigators.

What are some of the schemes?

A primary area of genetic testing concern is surrounding the use of CPT code 88271 Molecular cytogenetics; DNA probe, each (e.g. FISH: Fluorescence in Situ Hybridization probe).

Claim data often shows CPT code 88271 is billed frequently and with multiple units.  In reality, this area of testing is performed infrequently and primarily by larger laboratory companies with access to the necessary equipment.  Are you at risk for unsupported CPT code 88271 claims?  There’s a good chance.

What to look for?

Look for exposure to this procedure code over the past 3 to 5 years.  Identify the labs and other providers submitting claims, paying close attention to increases in the number of claim lines billed, the number of units per claim line, and both charges and reimbursement per claim line.

Once you identify potential abuse, there are several things you can do to determine the laboratory testing methodology that was used, when CPT code 88271 is billed:

  • Review the lab report itself for an explanation of the testing methodology employed by the lab.  Look for “DNA probe” or “FISH”.
  • Look at the laboratory website for a list of the tests they perform.
  • Call the lab and ask “Do you do FISH testing?”  If the answer is no, likely no submissions of CPT code 88271 are supported for that provider
In addition to concerns about CPT code 88271 itself, many claims are billed with excessive units.  For this procedure, units are based on the number of DNA strands or probes used by the laboratory analyst during the FISH test.  Several probes can be used at the same time.  Be sure to confirm with the lab, should you have concerns about the number of tests performed and billed.

Abuse of CPT code 88271 is not likely to go away any time soon.  Your data will help you determine any areas of concern, and monitor this issue into the future.

For more information, or if you have any questions or comments, please contact us at


%d bloggers like this: